154 Conversion Disorder (300.11)

DSM-IV-TR criteria

A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflict or other stressors.

C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of function or warrants medical evaluation.

F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Associated features

• Some people with Conversion Disorder may display la belle indifference. This is a relative lack of worry about their condition or its implications. Other people may act in a dramatic or histrionic manner though.
• Individuals being treated for Conversion Disorder may develop dependency issues and embrace an ailing role during the course of their treatment.
• Symptoms caused by Conversion Disorder usually conflict with established anatomical or physiological knowledge and explanations. Therefore, objective signs that indicate the presence of a traditional abnormality are frequently absent.
• Laboratory analysis of the condition typically do not yield any findings as well. The absence of any findings is a feature that may indicate that Conversion Disorder is the actual source of the problem(s).
• Dissociative Disorders, Major Depression, and Histrionic, Antisocial, Borderline, and Dependent Personality Disorders are mental disorders than can be associated with Conversion Disorder.
• Most conversion symptoms are neurological and usually relate to the loco-motor system. The motor symptoms include convulsions, paralysis, weakness, and dyskinesia. Sensory symptoms include paraesthesia or anesthesia, blindness or speech disorders (Heruti, Levy, Adunski and Ohry, 2002).

Child vs. adult presentation

The symptoms that children with conversion disorder experience are frequently limited to seizure or gait problems. There is a wide range of symptoms that adults with Conversion Disorder may experience. These symptoms may include the loss of sensation, paralysis, blindness, seizures, or a mixed presentation.

Conversion Disorder appears in adolescence or early adulthood. Presentation before the age of 10 or after the age of 35 is rare, though some cases have been reported around age 90. Conversion Disorders before the age of 10 are usually limited to walking impairments or convulsions (Heruti, Levy, Adunski and Ohry, 2002).

Gender and cultural differences in presentation

Conversion disorder is diagnosed more frequently in women than in men. An exact ratio has not been established, but most studies indicate that the ratios range between 2:1 and 10:1. It is more common for women with Conversion Disorder to eventually develop Somatization Disorder, but there is a strong relation between Conversion Disorder and Antisocial Personality Disorder among men. It is common for men who experience Conversion Disorder to have suffered an industrial accident or to have been in the Military. It is much more common for women to experience symptoms on the left side of their body than in their right side.

There are various links between Conversion Disorder and cultural factors. People in rural settings, lower socioeconomic levels, and with relatively less knowledge of psychology and medicine are diagnosed with Conversion Disorder more frequently than other populations. There is a higher incidence of Conversions Disorder in developing regions than in developed regions, and reports from the developing regions decrease as further development occurs. The conversion symptoms displayed by patients may vary based on their culturally accepted means of demonstrating distress. One must be aware that the religious and healing rituals of certain cultures may include characteristics that could be confused with symptoms of Conversion Disorder.

Some symptoms that might be linked to a conversion disorder in the United States may be a “normal expression” of anxiety in other cultures. In London at the National Hospital, the diagnosis of 1% of inpatients. In Iceland, the report is 15 cases per 100,00 persons.

Epidemiology

The prevalence of Conversion Disorder varies according to multiple reports, but the rates generally range from 11/100,000 to 500/100,000 in samples from the general population. About 3% of mental health clinic referrals are due to Conversion Disorder. Conversion Disorder is more likely to develop among older adolescents or young adults, women, and people from lower socioeconomic classes. According to one study, there was 1.2%- 11.5% of psychiatric consultations for hospitalized medical and surgical patients.

Etiology

The exact cause of Conversion Disorder has not been established by empirically supported data, but there are some theories about its development. Many contemporary theories claim that the development of Conversion Disorder is often sudden, and it is triggered by subconscious conflict, unresolved grief, sexual trauma, or other stressful situations. In essence, these theories state that people with Conversion Disorder convert their psychological distress into physical symptoms to avoid any further mental anguish. Disturbances in the central nervous system may increase the likelihood and/or severity of any somatic symptoms.

Other factors may influence the development of Conversion Disorder. There is some evidence that Conversion Disorder may be genetically transmitted, but there is not enough data to prove this conclusively. Socioeconomic factors are also known to influence the development of this disorder, but the exact manner in which they impact an individual has not been definitively identified.

According to Freud, suppression is the major defense mechanism involved in conversion because of the close relation between conversion conditions and traumatic events in the individual’s life. Freud states that an impulse, or a wish, that cannot be fulfilled due to negative connotations such as fear, shame, quilt, or anger is converted into physical expression (Heruti, Levy, Adunski and Ohry 2002).

Empirically supported treatments

There are no empirically supported treatments for Conversion Disorder, but there are a couple of methods that are believed to help people with this disorder. The most common methods are behavioral or cognitive behavioral treatments. Treatment plans need to be individualized due to the varying symptoms of each person, but there are some general guidelines. It is important to discover any psychological stressors an individual may have that precipitate somatic symptoms to cope with them. It is vital to help individuals recognize these stressors and to help them learn more adaptive methods for dealing with them. Manipulation of the patient’s social environment may be necessary in order to reinforce the patient’s non-symptomatic behavior.

Physical rehabilitation, due to motor functional imparities, should be considered an option as soon as possible, after physiological etiologies have been ruled out. Physical rehabilitation addresses the prevention of secondary disabilities due to the disorder.

Proposed Changes in DSM-5 (dsm5.org)

The work group is recommending this disorder be renamed from Conversion Disorder to Functional Neurological Symptoms.
Criteria A, B, and C must all be fulfilled to make the diagnosis:
A. One or more symptoms are present that affect motor or sensory function or seizure-like episodes.
B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience.
C. Physical signs or diagnostic findings that provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.

D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are discussing how conversion disorder relates to the Dissociative Disorders

Rationale:

Major Change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders
The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.
Major Change #2: De-emphasize medically unexplained symptoms
Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.
Major Change 3: Modify Criteria for Conversion Disorder

Changes are made in an effort to simplify the criteria for conversion disorder. First, we suggest removing the requirement that the clinician actively establish that the patient is not feigning. This is because (a) it is probably clinically impossible to prove that a patient is not feigning (Sharpe, 2003) and (b) there is no evidence that feigning of conversion symptoms is more common than feigning of other mental disorders. However as with other disorders positive evidence of feigning remains an exclusion, thereby differentiating conversion from factitious disorder and malingering.
Second, we suggest removing the requirement that the clinician has to establish that there are associated psychological factors . This is because (a) as with feigning, it is very difficult to reliably establish that relevant psychological factors are present in all cases and (b) the research evidence suggests that psychological factors can often be found but are not specific and have only a weak association with the diagnosis (Roelofs, 2005). The association with psychological factors has therefore been relegated to accompanying text rather than remaining a clinical requirement for diagnosis.
Third, we emphasize the importance of obtaining positive evidence of the diagnosis from appropriate neurological assessment and testing. Current diagnostic criteria require that the symptom, after appropriate medical assessment, is found not to be due to a general medical condition. In contrast to most other somatic symptoms, it can be usually be reliably determined whether neurological symptoms are due to an organic disease (Stone et al 2009). Additionally there are also findings on neurological assessment and investigation that positively suggest the symptoms are those of conversion (such as Hoovers sign for motor weakness or absence of seizure activity on an EEG during apparent seizures for seizures) (Hallett 2005; Reuber 2004; Stone 2005).

We suggest retaining Conversion Disorder in the Somatic Symptom Disorders section of the DSM. Conversion remains a condition defined by a somatic symptom that causes disability or distress and therefore sits comfortably in the new Somatic Symptom Disorders category that replaces somatoform disorders on grounds of utility. The alternative placement of this diagnosis is with dissociative disorders. The argument for moving conversion there is that the mental mechanisms involved are similar. However dissociation is a hypothetical process and moving conversion would (a) risk making an unjustified assumption about cause (b) lose the utility of grouping with other conditions that present with a somatic symptom.

Severity

There are few widely employed measures of severity in factitious disorder or conversion disorder.

For conversion disorder, the severity scoring might best be based on the severity of the associated disability (using a simple rating of mild, moderate and severe)